Coverage for Penbraya

[Melissasuewashburn]

I work in a pediatrics office and am having a hard time verifying if Penbraya (90623) will be covered by the different payers. I have an email into my local BCBS rep, but when I try to call Cigna, UHC, TRICARE, or Aetna they all are telling me it is plan specific if an immunization is covered. Does anyone have any information?

My boss wants to independently confirm coverage before we order as we were burned on some of the Vaxneuvance (PCV15) vaccines when we just went based on the reps information that it was covered.

 

[CBLENNIE]

The CDC committee just made the recommendation to cover Penbraya for ages 10-25 but it isn't on the actual CDC immunization schedules yet so some carriers may cover it now, but some may not. I found on the CDC's website that as an addendum to the 2024 Child and Adolescent Immunization schedule and the Adult schedule for age 19 years and up that Penbraya is being recommended on next year's schedule.

Additionally, while the FDA approved the vaccine the CPT code 90623 isn't effective until 01/01/24, so you would have to use an unlisted vaccine code for any claims for the remainder of 2023.

I found a policy for UHC commercial affiliates & individual exchange plans policy regarding Preventive Care Services: Vaccine Codes that was updated on 11/09/23 and it includes Penbraya on it with info on how to bill for 2023 until the new CPT code is effective 01/01/24.

I think you are going to find that there is going to be some lag in the coverage of this new vaccine because many payers will wait for it to actually be effective per the CDC immunization schedules since that is what they are required to follow for non-grandfathered plans under the ACA. Additionally, they are allowed a certain amount of time under the ACA to cover any newly recommended preventive services, some companies will make the update quickly like UHC and others may take as long as they are allowed under the timeframes laid out in the ACA mandate for preventive services.